Provider Demographics
NPI:1184132623
Name:ACADEMY DENTAL LLC
Entity type:Organization
Organization Name:ACADEMY DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-473-6455
Mailing Address - Street 1:488 N 100 E ST.
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606
Mailing Address - Country:US
Mailing Address - Phone:801-374-0867
Mailing Address - Fax:
Practice Address - Street 1:488 N 100 E ST.
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606
Practice Address - Country:US
Practice Address - Phone:801-374-0867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACADEMY DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8372408-9922125K00000X
UT372923125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes125K00000XDental ProvidersAdvanced Practice Dental TherapistGroup - Single Specialty